Provider Demographics
NPI:1427167105
Name:KLEIKAMP, THEODORE J (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:KLEIKAMP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 SW EASTRIDGE ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5064
Mailing Address - Country:US
Mailing Address - Phone:503-280-4555
Mailing Address - Fax:503-280-4559
Practice Address - Street 1:10200 SW EASTRIDGE ST
Practice Address - Street 2:SUITE 205
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5064
Practice Address - Country:US
Practice Address - Phone:503-280-4555
Practice Address - Fax:503-280-4559
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC91113Medicare UPIN
ORR108060Medicare PIN